Lecture 9 - Neurocognitive + Peds Flashcards
What is cognition?
System of interrelated abilities, such as perception, reasoning, judgment, intuition, and memory
Allows one to be aware of oneself
What is memory?
Facet of cognition, retaining and recalling past experiences
What is delirium?
Acute cognitive impairment caused by medical condition (ex: infection), substance use, or multiple etiologies
What is Dementia in comparison to delirium?
Chronic, cognitive impairment
Differentiated by cause, not symptoms
How do we treat delirium?
By treating the cause
–> Acute
What is the diagnostic criteria for delirium?
Key feature: Impairment in cognition
–> Disturbance in consciousness and a change in cognition
–> Develops over a short period of time
–> Usually reversible if underlying cause identified
–> Serious, should be treated as an emergency (25% of patients do not survive)
How do we assess for delirium?
Confusion Assessment Method (CAM)
Acute Onset + Inattention
With one of the following:
–> Disorganized thinking
–> Disturbances in consciousness
What are the behavioural/physical signs associated with delirium?
Attention wandering
Perseveration
Easily distracted
Daytime sleepiness
Night-time agitation
Restlessness
What are common causes of delirium?
–> Medications
–> UTI/Lung infection (geriatric)
–> Fluid and Electrolyte Imbalance
–> Hypoxia/ischemia
What are the major theories of causative factors for delirium?
Reduction in cerebral functioning, white matter, and damage of enzyme systems, the BB-Barrier, or cell membranes.
May also be reduced brain metabolism and imbalance of NTs.
Raised plasma cortisol levels during acute stress
Delirium is more common in which demographics?
More common in women
–> Also elderly, postoperative, cancer treatment pts
What is a primary cause of delirium in nursing homes?
Communication barriers associated with cognitive impairment and dementia
What will we focus our MSE on for delirium?
Must Assess patient baseline for comparison!
Cognition, orientation, logic
Behaviour changes
What two kinds of behavioural changes will be seen in delirium?
Hyperkinetic
–> psychomotor hyperactivity, excitability, hallucinations
Hypokinetic
–> lethargic, somnolent, apathetic
When is comes to delirium, what physical exam could determine the underlying cause?
Labs + lytes
What is the priority in delirium care?
- Rule out life threatening illness
- VS
- May need to stop medications
- ADLs + functional needs
What pharmacological interventions might be helpful for delirium caused by alcohol withdrawal?
Benzos
–> Associated with alcohol withdrawal delirium
Monitor for changes in MSE, extrapyramidal symptoms, hypoTN
What kind of social interaction can help a person experiencing delirium?
Short, frequent interactions
–> Orient them
–> Lower stimulation from environment
–> Provide sensory aids (if indicated)
What are the initial manifestations of dementia?
Possible loss of memory
Possible alteration of short term memory – acquisition of new knowledge
Loss of initiative and interest
Geographical disorientation
What are the S/S of intermediate dementia?
Difficulties recognizing loved ones
Behavioural changes (wandering, agitation, etc.)
Loss of long term memory and loss of procedural memory
Confusion and insomnia
Aphasia (knowing what to say, not finding words to say it)
Apraxia (Inability to execute movement)
Agnosia (inability to identify objects)
Hallucination, delusions & illusions
What are the S/S of advanced dementia?
Incapacity to assimilate new information
Incomprehension of words
Dysphagia
Immobility
Incontinence
Echolalia
Dependent for ADLs
How did the diagnostic criteria for initial dementia change in the most recent DSM?
Previously was memory loss, is now diffuse symptoms and geographical disorientation
What are the different causes of dementia?
Alzheimer’s (most common)
Vascular
HIV related
Related to trauma
Related to Parkinson’s, Huntington’s chorea’s, Creutzfeldt-Jacob, etc.
Frontotemporal dementia (memory loss is secondary to behavior alterations)
Persistent substance use (hallucinogens, alcohol, etc.)
What are the most likely causes of Alzheimer’s type dementia?
Beta-Amyloid Plaques
Neurofibrillary Tangles
Cell Death and Slowed Neurotransmission
Genetic Factors
Inflammation involved - unsure if cause or effect
How to treat dementia?
Establish a baseline in functional sphere to track disease progression
Manage cognitive symptoms and aim to delay cognitive decline
Treat non-cognitive symptoms - psychosis, mood symptoms, and agitation
Support caregivers!
What are the priority physical assessments in someone with dementia?
Self-Care
Sleep-Wake Disturbances
Activity and Exercise
Nutrition
Pain
In which stage of dementia are mood changes such as depression anxiety be more common?
Intermediate
What behavioural changes might be seen in dementia?
Apathy & Withdrawal
Aggression
Aberrant motor behaviour
Disinhibition + hypersexuality
Catastrophic reactions to everyday situations
What pharmacological interventions can be used for dementia?
AChEI like Donepezil
–> Alzheimer’s only
Antipsychotics
–> Symptom management
Antidepressants + Mood Stabilize + Anxiolytics
–> Symptom management
Why should you be careful when giving someone with dementia an antianxiety medication?
Paradoxical Reactions are a possibility
–> Causes increase anxiety
For people with dementia, we should avoid medication with anticholinergic effects?
We need to increase cholinergic responses between the neurons
What interventions can be helpful for those with dementia?
Validation therapy
Memory Enhancement
Maintenance of Language Function
Supporting Visuospatial Functioning
Should you reason with illusions and delusions in dementia?
Not likely to be effective
–> Redirect
Most children will develop ____ when experiencing stressors
Most develop “normally” despite them.
What is the diagnostic criteria for ADHD?
Inattention, hyperactivity and impulsivity that are present in at least two settings (school, home, friends)
How do stressors in childhood contribute to issues in adulthood?
Stressors might contribute to a reduced ability to develop adaptive coping mechanisms and strong interpersonal relationships
What are diagnostic criteria for ASD?
Impairment in communication + imagination/creativity
Impairment in social interactions
Restricted and/or stereotypical pattern of behaviours/interests
Ranges from mild, moderate, and severe.
What is ODD?
Negative, disobedient, hostile, and defiant behaviour toward authority. Severity related to number of setting where behaviours are observed.
Does not violate basic rights of others.
What is conduct disorder? What are the four types?
Pattern of antisocial behaviour that violates the basic rights of others and disregards social norms
–> Aggression, property destuction, theft, rule violation
What is the difference between conduct disorder and ODD?
Conduct disorder violates the rights of others and has disregard for social norms - often transitions into ADPD, delinquency/criminality
What is separation anxiety disorder?
After a child goes through a significant stress they may have altered social, academic or occupational functioning when separated from caregiver
S/S: Fear of being alone, sleeping alone, fear that parental figures will be harmed, somatic symptoms of anxiety.
How does GAD present differently in children?
Same as adults with an omnipresent feeling of worry
–> Need additional reassurance about all performances.
What differences in assessment and interventions differ between children and adults?
Must include parents or use them of source of information, and must consider the child’s developmental stage and capacity.
Pharmacotherapy in children is a….
Last resort
Why is dance and art therapy helpful for children?
Allows children to experience emotions in a social setting in a safe environment
–> Realigns with feelings of safety
What is the political role of nurses in mental illness in a pediatric environment?
To deconstruct the way society thinks about childhood mental illnesses and to promote advocacy.
What are beta-amyloid plaques and how to they affect the brain?
Cause of Alzheimer’s
–> Deposits that destroy cholinergic neurons
What are neurofibrillary tangles and how do they affect the brain?
Cause of Alzheimer’s
–> Exist in limbic system and contribute to memory disturbances
What chromosomes are involved in Cause of Alzheimer’s?
1, 14, 21
How does dementia with Lewy bodies present?
With fluctuating cognitive and early changes in attention and execute dysfunction
–> Parkinsonian features
What causes vascular dementia?
One or more cerebrovascular events
What kind of dementia has insidious and rapid onset with rapid progression of impairment and is rapidly fatal?
Prion
What medications should you avoid with dementia patients?
Those with anticholinergic effects
–> Like codeine
